Monday, January 18, 2016

Fentanyl and Heroin Overdose Deaths

There is a recent disturbing trend of rapidly increasing
heroin overdose deaths. Many of these are actually cases of heroin spiked with
fentanyl. Jacob Sullum discusses it here. The trend can also be seen in the CDC’s own numbers on drug overdose deaths.
(plot below). You can easily see the rapid rise in heroin-related deaths. The
CDC’s multiple cause of death database has a category called “other synthetic
narcotics”, which (according to the CDC) is mostly fentanyl (multiple cause of death codeT40.4). See the thick
light-blue line on the plot below. It looks like there’s been a steady increase
over the past 15 years, then a sudden leap in the past year. We’ll see what
2015 brings when those data are released. Fentanyl is an extremely potent
synthetic opioid that is 2 orders of magnitude more potent than morphine or
heroin. Given the potency, it’s incredibly easy to overdose on it. Illegal
suppliers generally aren’t *trying* to kill their paying customers. But the
very low cost and the extremely high potency are a deadly combination. Mistakes
are inevitable in a black market, where the natural regulatory forces of the
market operate poorly and the explicit regulation by government does not
operate at all.

A slight caution: Don’t make the mistake of *adding* the
heroin and “other synthetic opioid” deaths together. A death with more than one
cause listed on the death certificate will show up multiple times in the CDC’s multiple
cause of death data. There is some overlap between these deaths, which is kind
of my point. I suspect that many deaths from recent years labeled as “heroin”
overdoses were probably fentanyl overdoses. It’s just that some localities
haven’t caught on to the trend and so the toxicology reports aren’t showing it.

I wrote previously about the recent increase in prescription
drug poisoning deaths (here and here). I think that some proportion of those
deaths are unavoidable. For any useful medication, *some* amount of risk has to
be deemed acceptable. We can’t insist on a zero percent death rate, not if we’re
being reasonable. Whatever risk level (expressed as, say, a mortality per 100k
users) we deem acceptable, we shouldn’t freak out when more people take that
risk and the total number of deaths rises. While the number of deaths and the
total kilograms of opioids sold have gone up in recent years, the number of
deaths per kg of opioids sold is roughly constant. The risk as expressed per
legal dose (or per legal prescription) has remained steady. In other words, if
the risk was acceptable in 1999, it should be acceptable in 2014. (About 0.0005
deaths per gram sold, if the “Total Kg Sales” figures I have are accurate, in every year from 2002 and 2014.)

Heroin, on the other hand, has become more deadly. There
were 1.3 deaths per 100 users in 2002 and 2.5 deaths per user in 2014, though
admittedly both the numerator and the denominator used to calculate this figure
are volatile. (Estimates of number of heroin users taken from SAMSHA surveys,
estimates of heroin deaths from CDC multiple cause of death data, all publicly available.) *Most* of these deaths are entirely avoidable. Most overdose deaths happen
because people don’t know what they’re getting. Some heroin overdoses would surely
happen even in a regime of legalization, but most overdoses are a consequence
of prohibition for a host of reasons. One reason is that the drugs can be
spiked with toxic chemicals that the user doesn’t know about. Another reason is
that people don’t know what dosage they’re getting. If a network of heroin
dealers is busted, someone else quickly (*very* quickly) moves in to take over.
The new suppliers may be dealing something of higher purity than their
predecessors, and unwary users may accidentally overdose. A third reason, much overlooked,
is that people who are arrested for heroin use may temporarily get clean
while in jail. Upon release, they have lost their tolerance to the drug, but
they may return to using at levels they were used to. (This post by James Schneider suggests that the third reason is the most important, the
second second, and the first least important, although that might have changed in
very recent years.)

The solution is simple. Heroin users need only to
ask the pharmacist about the concentration and the recommended dosage. They should
ask about potential interactions with their current medications or other
recreational drugs they are currently taking. They should check the box to
ensure it came from a reputable distributor, that there are no toxic additives (such
as fentanyl), and should obtain a clean needle for…oh, shit. I forgot. None of
that is possible under drug prohibition.

This is one we can lay squarely at the feet of the drug
warriors. In principle, it’s possible to reduce the harm from even the most
reviled monster drugs, but that would require the ability to sell them at known
doses, without adulterants, through knowledgeable, responsible dealers who warn
their users of the *real* hazards. Drug prohibition has made this scenario impossible.
Let’s stop pretending there’s a law enforcement solution to this problem. A
legal “harm reduction” regime, like what’s in place in Switzerland, will get us most of the way there.